by Allen Barringer
For seven years now we have lived with “Obamacare,” the Affordable Care Act, and now we are engaged in rewriting it as the American Health Care Act, and, yes, it’s “all very complicated.” One thing already is clear: both Democrats and Republicans talk about “affordable, quality health coverage for all Americans” — but neither the ACA nor the proposed ACHA truly lives up to that description.
I understand that standards of health care are contentious. We don’t agree on what is “quality” or “adequate” care, let alone “humane,” and we don’t even agree how limited medical resources, such as transplantable organs, should be allocated. But until this year, I thought we did agree on equal access to whatever it is the government provides. If there is a health entitlement at all, it should be available to all.
Health care has long been a government responsibility. From medieval times, the established Church organized hospitals and administered the poor house and other components of the social safety net, while the King dealt with public sanitation, quarantines and military health. The Enlightenment brought about a greatly expanded government role in public improvements, including public health, during the 17th and 18th centuries. Those traditions were brought to the American Colonies; indeed, persons drafted for their medical skills were among the earliest settlers in Virginia and in New England. By the 19th century, and particularly after the Civil War, public health (including, individual care for the ill and the indigent) was generally recognized as a concern and a responsibility of the States.
In Virginia, the first mental hospital was built in Williamsburg in 1773 at the urging of Governor Fauquier, and Western State opened in Staunton in 1825. Jefferson’s Anatomical Hall, completed in 1826, was an early building for medical instruction at the University of Virginia. The Hampden-Sydney “Richmond Department of Medicine” opened in 1834, becoming the Medical College of Virginia in 1854. After the Civil War health activity in Virginia exploded due to the legacy of military health care and new learning about the importance of cleanliness, the source of infections and epidemics, and use of anesthesia.
Virginia’s State Board of Health came in 1872. Virginia mandated vaccinations and sanitary sewers and quarantine regulations in its port cities. In 1889, a young doctor recently trained in Vienna, Austria, in the latest medical and public health practices, was hired as Professor of Medicine at the University of Virginia. He quickly convinced Charlottesville and university authorities that to maintain the good health of university students and faculty it was necessary to address the health of the whole community they lived in. Eventually he persuaded the General Assembly to support this approach also. Teaching students through the practice of public health was the hospital’s mission. Teaching better health practices to the community and abating communicable disease at the source was its outreach.
Health care for the community means everyone in the community. Disease afflicts rich and poor and all races and occupations alike; every occupation has its hazards. The University hospital which Professor Barringer, my grandfather, founded and promoted so tirelessly was from its inception open to the Charlottesville community without regard for university affiliation, status, gender, race, or ability to pay. Many medical professionals and hospital administrators in Virginia still provide medical care on those principles, although they try to obtain payment when they can. And health remains an object of State concern and appropriations. For example, just a few months ago, Governor Terry McAuliffe announced State measures to make counteragents available at little or no charge aimed at combating the growth of opioid addiction, which he described as “a public health emergency” in Virginia.
The involvement of our state and federal governments in providing health care is so pervasive that we cannot pretend this is, “by default,” a private responsibility. The details of how the government goes about providing “affordable, quality health coverage for all Americans” are not as important as the affordability, the quality, the coverage offered. And this is a Virginia issue, not just a federal one.
Medicaid has a state budget impact, and there is talk of turning the entire health entitlement spectrum into federal block grants to the States. When McAuliffe tried to expand Medicaid under the ACA (essentially “free” to Virginians for a time, at the expense of the federal government), the General Assembly turned him down. That seemed to many observers (including me) to be more a partisan rejection of Obamacare than a vote against the public health and economic welfare of Virginians — but it certainly had the latter effect. And according to the Congressional Budget Office, the ACHA as proposed would substantially aggravate that effect.
Government support for health care has two rationales. One is economic. A healthy community is more productive, with less missed work, less down-time, less family distraction and dysfunction, and less threat of a catastrophic epidemic. Even if it isn’t you who is ill, you have an economic stake in the health of those around you, and you receive a direct benefit from the investment of your tax dollars in health care for others, not to mention the indirect benefit of a higher quality of community life. There is no distinction between individual health and public health in this regard.
The other rationale, of course, is compassion. Compassion is a moral imperative, and while I hear very little about compassion from Republicans these days it’s high time they re-discover it. The parable of the Good Samaritan is in the Bible, not a book of etiquette. Working in health care is an intensely rewarding endeavor, which attracts churches, charities, and all those many individual volunteers who devote their time to helping others. Not incidentally, compassionate policies also appeal to voters. Continue reading